the Australasian Colonies. Such increase, if actual, is not surprising, considering the great growth of some colonial cities, and the consequent crowding of the population in these centres. It might also be looked for in a population among which are descendants of so many who have sought the climates of Australia or New Zealand on account of threatened or early consumption. In the younger colonies it is just of late years that the second generation of these colonists has been reaching the early adult life at which tubercular tendencies are liable to manifest themselves in those who come of a stock predisposed to it.

The boon which any means of decreasing the number of sufferers from this disease would prove may perhaps be better understood by my naming the approximate number of deaths from it in those countries in which we are most nearly interested. In England and Wales some forty-five thousand succumb to it yearly; in Australia, about four thousand; in New Zealand, about seven hundred. Add to this tribute to death the suffering of the afflicted, the burden laid on their relatives, the loss of labour the community suffers—not only in those laid aside by the disease, but in those whose time is absorbed in nursing and caring for them—and we can realise that the benefit derived from the practical extinction of even such a fell disease as small-pox would not exceed the gain made through the extinction of tuberculosis, were that possible.

Thirty years ago, or even less, the general idea of consumption, as it was and is popularly called, was that it was a disease liable to occur, especially in certain families and constitutions, and any assertions as to its more exact cause were of a very ill-defined nature. Climate, dampness of atmosphere, impure air, and many other circumstances were recognised as predisposing causes, but the ultimate exciting cause was but matter of speculation. Here and there in medical literature are found suggestions that it was communicable from one individual to another, and cases were often adduced to support this view. But the evidence was insufficient for the infectious nature to become a generally-accepted fact; and the theory of infection was so general that it pointed out no special means of limiting the spread of the disease.

It must not, however, be assumed that this uncertainty prevented any attempts to control the disease, and that no successful means were adopted to restrict its ravages. A reference to the statistics of mortality for England and Wales during the first five years of Her Majesty's reign show that about sixty thousand died annually from this cause, being some 3,880 out of each million of the population living. In the five years ending 1891 there died annually from the same

cause only some forty-five thousand, notwithstanding the great increase of population. Reckoned per million of population, this represents only 1,635, instead of the 3,880 of fifty years previous. The decrease, moreover, had been progressive during all that time through each quinquennium, and was no doubt due to general sanitary improvements, but not to measures directed especially against tubercular disease. The ventilation of work-rooms, restriction of hours of labour and of the ages at which children were allowed to work, and other kindred measures have acted beneficially against all diseases which like tubercle best take root in those already weakened in constitution. The war waged was with disease in general, or perhaps it may be better expressed as an attempt to lessen the predisposing causes of disease, while the knowledge of the exciting cause was, in the case of tuberculosis, absent.

Tuberculosis, as its name indicates, is characterized, as regards its pathology, by the formation in the affected organs of the body of small masses of abnormal material called tubercles. These tubercles vary in size. In following the process of the disease one may note that, at first hardly perceptible, these little masses increase in size, and there gradually appears in the centre of each a yellowish colour, due to the death of the tissues in this part, and the formation from them of a cheesy substance. These masses continuing to grow coalesce with each other. After a certain stage is reached the centre of the cheesy mass begins to soften, and an abcess is formed, which finds an outlet—frequently through the normal passage of the affected organ; in the case of the lung, through the air-passages. In this way the process of excavation goes on, and a progressive case leads to the gradual destruction of large areas of the affected organ.

I go into these details to explain that until recent times a satisfactory explanation was wanting as to what caused these tubercles, which are essentially the disease. Now we know that they are due to the presence of a special germ, which finds a suitable soil for developing in those whom we in consequence call predisposed to consumption. No case arises of itself without the entrance of the tubercle germ into the body, and without its finding there a suitable resting-place.

The knowledge that tubercles depended on a special disease germ was arrived at only after innumerable researches, and for many years the results of these researches provided only material for dispute among those making them. One of the first steps towards the proof of the communicability of tuberculosis was the production of it by the injection of cheesy material from the tubercles into the bodies of such animals as guinea-pigs and rabbits. Later it was shown

further that after feeding these animals on food with which tubercular material had been mixed typical tubercle developed in them. This is an experiment which has been frequently made accidentally; one reported instance happened in the south of France, where a consumptive went to live at a poultry-farm. The expectoration was disposed of in such a way that the fowls' food was contaminated. The investigation of an epidemic which destroyed the fowls proved that they had contracted tuberculosis. Another example, of which several instances have been recorded, is the infection of pigs fed on the milk or flesh of tubercular cattle. The last doubt as to the infectious nature of tubercle was removed when Koch showed that a germ was present in tuberculous tissues, could be isolated, could be grown on suitable media apart from the body of any animal for several generations, and could then, when injected as a pure cultivation into other animals, produce the same typical disease.

There is little difficulty in demonstrating this germ in the expectoration of the consumptive; indeed, the abundance in the discharge from many cases presents a ready object-lesson of the danger a consumptive individual may be to those who come into contact with him or his surroundings.

After this scientific proof of the relation of cause and effect between the germ and the disease, the natural corollary was that, given a means of killing the germs, the transference of the disease was avoidable. The germs themselves are comparatively readily killed, but, owing to what is known as spore formation, the difficulty of exterminating them is much increased. Spores occupy in relation to germs a similar position to that of seed in regard to plants. A field of thistles, we know, may to all appearance be quite cleared by the simple process of killing the plants, but if they have seeded the recurrence of conditions favourable to the development of the seed—proper heat, moisture, and suitable soil—is followed by the appearance of fresh thistles.

Similarly, the spores of the tubercle bacillus may escape, and often do escape, destruction when the bacilli themselves are destroyed, and remain dormant until they find themselves in circumstances favourable to their development. They then soon become active agents, capable each one, in suitable soil, of producing myriads of its own kind. This suitable soil is found in the bodies not only of man, but of many animals with which he is brought into closest contact—the cow, the pig, the fowl, and many others. Where man or domestic animals are, the presence of the tubercle germ or its spores affords a constant opportunity for the development of fresh centres for its propagation. The infected organs of an animal may be regarded as the manufactories of the poison; the

whole animal as the distributing agent. Take, for instance, a case of advanced consumption of the lungs in the human subject, expectorating daily large quantities of broken-down tissues in which are contained innumerable germs. Unless proper care is taken—which hitherto has rarely been done—the whole surroundings are contaminated, the carpets and furniture are almost necessarily soiled, and the handkerchiefs are often, if not usually, sent to be washed along with those of other people. Experiments show that the very air is infected. At the Brompton Hospital for consumptives, near London, glass plates smeared with glycerine were placed for five days in one of the ventilating-shafts of the hospital. From what was deposited on these plates were demonstrated bacilli of tubercle in fair numbers. In a thoroughly purified ward in which a number of patients not consumptive were placed no bacilli were found in the air carried off by the extraction-shaft.

In the rooms occupied by consumptives not only are bacilli probably in the air in small numbers, but dust is formed of dried expectoration, and in this a still greater danger of dissemination lies. The spores of the germs survive in such dust, being much less susceptible to destructive influences than the germs themselves. They are unaffected by dryness, by a high degree of heat, and a strength of antiseptic solution much stronger than that which will kill the germs. Buried in the ground, they are found months later to retain their vitality. In the form of dust they are especially liable to reach the air-passages of man—his most vulnerable point in early adult life. Hence the danger of permitting consumptive patients to share bedrooms with others, or on board ship to share a cabin with fellow-passengers, and the danger of permitting consumptive tourists to occupy rooms in public houses of accommodation, hotels, or boarding-houses.

In adult life, as I have just said, tubercle most frequently affects the lungs. In childhood, however, the digestive system is most frequently attacked, and that in the form of consumption of the bowels. There is strong presumptive evidence that in these cases the virus has entered the body in the food. It has been shown by experiment that animals with whose food tuberculosis matter has been mixed show signs of the disease first in the alimentary tract. The greatest source of danger to children is milk from tuberculous cows, and there is, unfortunately, little doubt but that in times past, and, indeed, even at present, the contamination of milk with tubercle germs is by no means a rare occurrence, and what in a pure state ought to be the most suitable food for the young is converted into a means of giving what is practically poison. Tubercle in the cow shows itself with comparative frequency

in the udder, and an animal may often be in apparent good health at a time when there is discharged with the milk the broken-down material of advanced tubercle.

Another source of danger to man is the use of the flesh of tuberculous cattle as food. It is by some held that there is little danger in this unless the disease is in an advanced stage; but as a result of further recent investigation there would appear to be a grave risk incurred if there has been any tubercle whatever in the carcase. Probably at times the process of breaking down of tissues accompanying the growth of tubercles leads to the penetration of the walls of a bloodvessel and the introduction of the germs in this way into the blood. Once introduced into the blood they are distributed to all parts of the body. In this way the meat of the tuberculous animals may contain germs, although the “naked-eye” appearance is healthy.

I have dwelt thus long on the pathology and distribution of tubercles, and on the means by which infection is carried, because on these depend the precautions which must be taken to prevent it, and, of course, any legislation to this end. We have seen that the disease may be conveyed to man either from man or from some animal, and it will be convenient to discuss the subject of State prevention in connection with each of these sources separately.

While restriction is perhaps as necessary in one direction as in the other, the difficulties and the opposition to proposed reforms are not the same. As regards prevention of contagion from animals the difficulty is chiefly a financial one. In the case of preventing the spread of tubercle from man to man there is not only the financial difficulty, but also the opposition which always arises when reform is proposed in the habits of a community in any direction, especially where individual liberty or family life are likely to be affected by the change.

It is also convenient to consider these sources of infection separately because at the present time restrictions are in force to prevent the spread of tubercle from animals. There is as yet no restriction placed on any human being who, being, through tuberculosis, a source of danger to his fellows, is yet unwilling or incapable of adopting necessary precautions for their safety.

Turning first to the question of infection from animals, we have to regard especially those whose flesh is used for food, or which are producers of food in the form of milk. Practically we have to deal with cattle. Infection from other animals is comparatively rare. In the Australasian Colonies the prevalence of tuberculosis among cattle is not so great as in the northern countries of Europe, where the animals live less natural lives, where pedigree stock are more pampered, and

where in large towns, and even in the country in winter time, a large proportion of the milk-supply is drawn from stabled cows. Still, tuberculosis does exist to some extent in New Zealand, and the more our herds are subjected to proper examination the more clear it is that the disease exists to a serious degree.

Provision has been made by Government for the inspection of stock by Government officials—mostly capable veterinary surgeons—and for the destruction of tuberculous animals. To secure proper inspection of abattoirs and dairies it only requires that the local authorities should set in motion the machinery provided for the purpose. Hitherto such inspection as there has been by the local authorities has been intrusted to those who, as a general rule, do not profess to have received any expert training such as would fit them to detect any but the grosser cases of disease. There is a necessity for properly-trained officials, since the detection of disease in either living or dead animals is not always an easy matter. Often, for instance, tubercle appears first in the udder of a cow when it may be apparently in good health. It is also not at all an infrequent occurrence for decided signs of the disease to be found in the internal organs of animals slaughtered for food which during life were apparently sound. In each of these instances inspection by expert officials would be necessary. To provide this an expenditure is needed which the local authorities as yet will not face. Each borough or highway district forms a local sanitary authority by itself, and, in consequence, cannot really afford the expense which a proper carrying-out of the Public Health Act would entail. A combination of forces so as to place a large district under the control of a competent sanitary officer would render a solution of this difficulty more easy.

In many European towns where there is a properly-organized department to supervise municipal sanitation, not only is an exact naked-eye examination made of all meat for human consumption, but there is a proper staff, whose duty it is to make a microscopic examination of any suspicious material. In Denmark, a country which depends much on its dairy produce, the maintenance of efficient dairy inspection has become a matter of the gravest importance now that the question of the dissemination of tuberculosis through milk has arisen. One large private dairy association employs no less than six special veterinary surgeons, as well as the local veterinary practitioners, to keep constant watch over the herds that supply its milk. One of these veterinary surgeons examines about eight hundred cows each fortnight, making a careful note of the condition of each animal. Much remains to be done before our colony can compete with dairy arrange-

ments such as these—at any rate, in matter of exported produce guaranteed free from the poison of tuberculosis.

Farmers and dairymen are not unfavourable to proper inspection and control. Hitherto they have seconded well such attempts as have been made in the direction of reform. The practical difficulty so far has been the early diagnosis of the disease. It is difficult often to state with certainty whether an animal is tuberculous or not. Latterly there has been used for this purpose a substance called “tuberculin,” prepared from the germs of tubercle themselves by the German scientist Koch. On its first discovery it was hoped tuberculin would prove a cure for tuberculosis. This expectation has not been fulfilled; but it has been turned to good account by its use for diagnostic purposes. Its value in this direction is owing to the fact that its injection into the bodies of tuberculous animals is followed by symptoms not observed in those free from the disease. A tuberculous animal can thus be readily and early detected. A trial of this agent is now being made in New Zealand, and, if the daily Press is to be believed, with startling results. It is hoped that by this means the introduction of pedigree cattle actually affected by tubercle may be avoided, and thus the introduction into our herds of fresh strains predisposed to the disease may be in part prevented; also, that its use in herds where there is reason for suspecting tubercle may enable an early detection and removal of the affected animals.

Turning now to consider the prevention of the spread of tuberculosis from man to man, we find the matter one of much greater difficulty. In the case of infected animals, once the diagnosis is made the proper course is clear. The animals should be slaughtered, and the danger from that source so ended. The affected animal is sacrificed for the good of his fellows and of man. When, however, one of our fellow-beings is the unfortunate sufferer, the common instincts of humanity, and the sacredness of human life, demand that we should not only attempt to effect a cure, but, failing that, should prolong his life so long as possible, and in such comfort as can be afforded him, notwithstanding that he is a source of danger to those who must come in contact with him, unless careful precautions are adopted.

The cure and care of consumptives is a duty just as binding as the prevention of its spread to others. It is with this in mind that from various quarters in these colonies demands are being made that tuberculosis should be placed in the same position as other infectious diseases. There are those who are themselves unable to provide proper treatment and care, or from ignorance, incapacity, or want of will to do otherwise are liable to expose others to the risk of incurring the disease.

By regarding tuberculosis as other infectious diseases are regarded these individuals would be considered the care of the State, and be placed under suitable treatment and supervision. The rest, more fortunately situated, can make provision for themselves. As in the case of other infectious diseases, it is the poor for whom such provision is especially needed; but it would be a boon to many who would under ordinary circumstance be quite independent of State aid, and who would be in a position to recoup the State any expenditure on their behalf, but could not individually afford the expenditure necessary to provide separately adequate treatment or isolation.

It is no uncommon occurrence for a member of a family to be unfitted, by consumption, for any employment, and to be thrown a burden on his friends. From the first his case has been hopeless, because his means do not enable him to obtain the fresh air or more suitable climate which may be essential to strengthen his tissues sufficiently to resist the attacks of the tubercle poison. Going from bad to worse, he lives on, in a small house, with his wife and children, or brothers and sisters, who are obliged to occupy the same rooms, and who must be thus exposed to the risk of infection. What wonder that under such circumstances, which are by no means imaginary, one member of a family after another succumbs to the same disease, the whole family becoming impoverished by the struggle to provide the nursing and other attention required.

One of the first principles in the treatment of infectious diseases is that the patient should be isolated to such an extent that the risk of infection being carried to others is minimised, and it will be necessary to apply this principle to consumption, modifying the means adopted in consequence of the chronicity of the disease, and in accordance with the special ways in which the danger of infection presents itself.

For the State to exercise control it would be necessary for cases of tuberculosis to be notified to proper authorities, and that an efficient inspector should see that all due precautions were taken in each case, where desirable instructing the patient and his friends as to what was necessary. In cases where the proper conditions could not be fulfilled he should have authority to remove the patient into proper surroundings—i.e., some institution provided by the State—a special hospital for consumptives. It is only in certain stages of the disease that such compulsory removal would be necessary.

At the present time notification is, unfortunately, the full extent to which the machinery provided by law against an infectious disease is made use of. The local health authorities have appointed no capable inspector, and, practically, any attempts at limiting the spread of an infectious disease are

due to such care as the patient, his friends, or the medical adviser may suggest. It is so customary for consumptive patients to neglect all precautions against infection that proper control by competent inspection would be absolutely necessary.

A special hospital for consumptives, into which, when necessary, patients should be compulsorily removed, should, however, not be instituted merely for this purpose. It should be such an institution as would induce patients to voluntarily seek admission. It should be the receptacle of all cases unable to obtain proper care at home. It would relieve the general hospital of many chronic cases, which occupy beds to the exclusion of those needing more urgent treatment—cases which are a constant cause of disturbance to the other patients, and a source of danger to others in the same ward whose powers of resistance have been weakened by illness. Such a special hospital would, however, not be sufficient in itself. Institutions should be established where consumptives in the early curable stages of the disease might be received with a view to cure. While the special hospital would be the centre of any such organization, and afford a home to those in the more advanced and therefore more infectious stages of the disease, and to those whose recovery could not be expected, for those in the early stages a special sanatorium should be built, in localities specially chosen on account of the suitability of climate. It should be possible to manage these so as to defray at least a part of the cost of their maintenance by affording to those able to work suitable outdoor employment. A special department for those able to pay should defray its own expenses. It would be an advantage, in that hotels and boarding-houses should not, in the interests of the public, be frequented by consumptives unless properly arranged and supervised for that purpose. And, on the other hand, ordinary places of accommodation in the country are, as a rule, unsuited to the needs of the consumptive, who, instead of the comforts and attention of home, finds too often, amid strangers and strange surroundings, unsuitable accommodation and a want of small attentions which but hastens the development of the disease.

The general principles on which these suggestions for State interference and supervision are based are not new. The State has, for instance, already provided proper institutions for the cure and care of mental cases, not only because an insane person may be a danger to his fellows, but because special treatment is required, and because in many cases the cost of maintaining a patient in an asylnm is readily borne by those who would be unable to provide separate attendance and treatment in their own homes. So, too, with the provi-

sion already made by the State for the care and treatment of acute infectious diseases. The novelty is the application of the principle to tuberculosis. It was this same novelty which attracted so much attention to a recent legislative proposal of our Government to exclude tuberculous individuals from the colony.

A simple affirmation that it is desirable to exclude from any community those who are liable to introduce disease would hardly meet with contradiction. Thus postulated, and from the point of view of the community in which such undesirable immigrants might wish to settle, there would seem to be little ground to question the propriety of exclusion. That from the point of view of others doubts as to the right or propriety of exclusion may arise we had evidence only a few months since, when a proposal was made to enforce it by Act of Parliament. The derision with which the proposal was met in other countries, and, indeed, among many of ourselves, showed that other considerations had to be taken into account besides the mere good or ill from a health point of view of the present inhabitants of New Zealand.

I will take it as an axiom that any individual is justified in refusing to render himself liable to disease through contact with an infected stranger, and to repulse his intrusion into his house. It would be but an amplification of this axiom to apply it to nations instead of individuals. It is the widened application which is called in question: hardly, however, in its general sense; rather in its application to special diseases. The right of a man suffering from small-pox to carry with him into any country the possibility of infection is universally denied; yet the claiming of a right to exclude a man suffering from consumption—in other words, afflicted with tubercle—is regarded, altogether apart from the supposed harshness of the measure, as absurd. The difference here is, of course, between a disease like small-pox—now fortunately comparatively rare, but when it does appear presenting its horrors by direct and almost immediately visible sequence—and a disease which, like tuberculosis, is the commonest scourge of almost all lands, and which, though decidedly infectious, spreads almost imperceptibly and insidiously. Familiarity with it prevents its horrors from being regarded with the same feeling of repulsion.

There is, however, another disease — leprosy—with the closest relation to tubercle, to which great abhorrence is felt and shown in almost all civilised countries, probably more from a sentimental reason or a preconceived idea than from any actual repulsiveness which is presented. In its last stages, and in certain forms, it is no doubt often most loathsome, but in an ordinary case there is nothing of this kind.

Leprosy is not a readily communicable disease; in fact, until quite recently doubts were entertained that it is communicable direct from one individual to another. Much of the evidence that it is infectious is derived from the similarity of its cause to that of tubercle. In spite of this, leprosy in the Australian Colonies is most strictly dealt with. The affected are isolated in proper homes. There are, it is true, few cases in comparison with the number of cases of tubercle, and the prospect of complete control and extinction is greater; but the greater the evil the greater the necessity of the remedy, and it is certainly anomalous that so much should be done in the case of a disease relatively less infectious and less widespread while no restrictive measures at all are taken against tubercle in man.

The exclusion of consumptive individuals from our shores is not only justifiable on sanitary grounds, but in accordance with the first principles of self-preservation. The difficulties that present themselves are in the practical carrying-out of enactments against such immigration. In advanced cases of disease there would be little difficulty, since the symptoms are well marked; but the ordinary case of tuberculosis emigrates at an early stage, when the symptoms are discoverable only by a detailed expert examination, and when to all outward appearance the person may be in tolerably good health, showing better condition than many suffering merely from some trivial transient ailment. I think I am warranted in saying that most of those in the early stages of consumption who enter this colony would, apart from an expert examination, be detected only through their own statement, if given. Evasion of the law would be comparatively easy, unless intolerable and expensive arrangements were made to subject the whole of our incoming passenger trade to detailed examination—an examination much more rigorous than that insisted on under any quarantine law. It is unlikely that any legal enactment would be properly enforced which would so disproportionately interfere with the commercial relations of the colony. The tendency of legislation in Europe at the present time is such that in England the last vestige of quarantine was abolished less than a year ago. The organization of the sanitary authorities there is such that it is felt that while the health of the community itself is properly cared for little is to be feared from without. Ships arriving in any port are under the local sanitary authorities for the time being, and are treated as any house in the district might be treated.

What is needed in the way of restriction of immigration of consumptives is that advanced cases, already a danger to those about them, should, if possible, be prevented from travelling to the colony. If carried on any ship means should

be provided on board that they may be berthed apart from other passengers, in quarters which could afterwards be thoroughly disinfected. When landed they should not be permitted to reside in any public lodging-house—they should, in fact, be subject forthwith to such regulations as might be in force in regard to our own consumptives. Unless friends were able to provide accommodation for them, approved by the sanitary authorities, they should be transferred to the Government institutions at their own cost, or at that of those introducing them. In the majority of such cases there would be no hardship. Instances are not rare where the change from a regular life on board ship to unsuitable lodgings in a strange land, and among strangers unable or incapable of rendering even necessary services to an invalid, is followed by a rapid loss of what little strength is left. The pitifulness of the case is intensified by the misery of loneliness and want of care. Such cases as these would, at any rate, be humanely cared for. Few would ever be sent to our shores were the shipping companies held liable to a penalty for knowingly carrying such passengers, and if better information were circulated in Europe regarding the hopelessness of expecting benefit to be derived by such through emigration to these colonies. Too often such cases are sent away from home either that their relations may be rid of a troublesome care or in a wild hope of improvement, which only ignorance could encourage. The notice which has been taken in the European Press of the Undesirable Immigrants Bill may be of service by limiting such immigration. The proposed legislation is a welcome sign in that the Government has recognised by it that tuberculosis is an infectious disease, and has shown itself sensible of its responsibility in regard to preventive measures. Such good, however, as it would have effected could be obtained by the adoption of measures directed against the disease already existing in the colony and the extension of the scope of these measures to vessels arriving in our harbours.

I have placed before you a short account of what at the present time seems desirable for the State to do in the way of preventing consumption. I have endeavoured to find reasons for such proposals as have been made. That they would do good if carried out there can be no doubt. The exact extent to which they would diminish the prevalence of tuberculosis it is impossible to predict. Their aim should be the extinction of the disease—a result obtainable only gradually and after a long period of time.

In these days of easy communication between different countries, to obtain such a result similar measures must be adopted by those communities with which there is inter-